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Falkner F, Thomas B, Mayer SA, Didzun O, Knoedler L, Panayi AC, Hundeshagen G, Vollbach FH, Gazyakan E, Kneser U, Bigdeli AK. The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction. Microsurgery 2024; 44:e31212. [PMID: 39046178 DOI: 10.1002/micr.31212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/17/2024] [Accepted: 07/05/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options. METHODS Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared. RESULTS A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9). CONCLUSION The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.
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Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Simon A Mayer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Oliver Didzun
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Leonard Knoedler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Felix H Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Center Ludwigshafen, Ludwigshafen, Germany
- Department of Hand and Plastic and Surgery, Heidelberg University, Heidelberg, Germany
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Kim TH, Choi JW, Jeong WS. Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green. Microsurgery 2024; 44:e31190. [PMID: 38828550 DOI: 10.1002/micr.31190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases. METHODS We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details. RESULTS This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels. CONCLUSIONS Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.
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Affiliation(s)
- Tae Hyung Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Shik Jeong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Dixit PK, Karmakar S, Singla P. Innervated vastus lateralis muscle: complementing and completing the anterolateral thigh flap for abdominal wall reconstruction. BMJ Case Rep 2024; 17:e258080. [PMID: 38769023 DOI: 10.1136/bcr-2023-258080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Reconstruction of composite abdominal wall defects is challenging. An anterolateral thigh (ALT) flap has established itself in the algorithm for abdominal wall reconstruction. Augmenting innervated vastus lateralis (iVL) muscle to ALT has added advantages. We describe previously unreported advantage of ALT with iVL.A woman in her 30s, suffering from Mullerian adenocarcinoma with metastasis to the right anterior abdominal wall and right inguinal lymph node, was taken for wide local excision and reconstruction. After excision, there was a 15×12 cm defect of the anterior abdominal wall. We reconstructed the defect with prosthetic mesh and pedicled composite ALT and iVL. There was venous congestion in the ALT flap and it could not be salvaged. We debrided the ALT flap and applied split skin graft over iVL. The grafted and donor sites healed well. The patient was able to do moderate strenuous activities. The presence of iVL allowed us to get away with minor procedure and averted the need for another flap.
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Affiliation(s)
- Pawan Kumar Dixit
- Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpi Karmakar
- Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Priyanka Singla
- Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Martić K, Vojvodić B, Gorjanc B, Budimir I, Tucaković H, Caktaš D, Žic R, Jaman J. Feet Salvage Using Anterolateral Thigh Flaps after Severe Frostbite Injury: A Case Report. J Pers Med 2024; 14:389. [PMID: 38673016 PMCID: PMC11051273 DOI: 10.3390/jpm14040389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Frostbite is a severe injury characterized by tissue damage due to exposure to freezing temperatures. It often necessitates prompt medical intervention to prevent further complications such as necrosis and amputation. This case report explores the successful use of bilateral anterolateral thigh (ALT) free flaps for feet salvage in a 19-year-old male refugee from Gambia who suffered severe frostbite injuries. CASE REPORT The patient, found after six days in freezing conditions, exhibited necrosis on multiple toes. Initial management included stabilization, intravenous fluids, and rewarming. Subsequent necrectomy and amputation revealed exposed metatarsal bones, necessitating a meticulous reconstructive strategy. Bilateral ALT flaps were chosen to preserve walking function, with a staged reconstruction involving multiple operations. The patient's progress, from inpatient care to outpatient follow-ups, is detailed, emphasizing the challenges and decisions in managing severe frostbite injuries. RESULTS The surgical intervention utilizing bilateral ALT flaps successfully salvaged the patient's feet. Throughout the postoperative period, wound care, rehabilitation, and outpatient monitoring contributed to positive outcomes. Despite challenges associated with the patient's ethnic background and nutritional status, the staged reconstruction facilitated effective healing and functional recovery. The use of ALT flaps provided a reliable solution with minimal donor site morbidity. CONCLUSION This case highlights the efficacy of bilateral ALT flap reconstruction in salvaging feet following severe frostbite injury. The successful restoration of foot function underscores the importance of early intervention and tailored reconstructive approaches in frostbite management. Despite patient-specific challenges, including nutritional status and limited healthcare resources, the use of ALT flaps facilitated optimal recovery and functional outcomes. Importantly, this report is unique as it describes a novel case of feet salvage using bilateral ALT flaps in severe frostbite injury, with only one similar case previously reported in the literature. This emphasizes the rarity and significance of this specific surgical approach in frostbite management.
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Affiliation(s)
- Krešimir Martić
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
- Department of Surgery, School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
| | - Borna Vojvodić
- Clinic for Traumatology, Sestre Milosrdnice University Hospital Center, Draškovićeva 19, 10000 Zagreb, Croatia
| | - Božo Gorjanc
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
| | - Ivan Budimir
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
| | - Hrvoje Tucaković
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
| | - Doroteja Caktaš
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
| | - Rado Žic
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
- Department of Surgery, School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
| | - Josip Jaman
- Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia; (K.M.); (B.G.); (I.B.); (H.T.); (D.C.); (R.Ž.); (J.J.)
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Liang W, Chen HF, Jeng SF, Shih HS. Pushing the Limits of Reach for the Pedicled Anterolateral Thigh Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5727. [PMID: 38596578 PMCID: PMC11000755 DOI: 10.1097/gox.0000000000005727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/15/2024] [Indexed: 04/11/2024]
Abstract
The pedicled anterolateral thigh flap, although tremendously versatile, may be limited in reach, especially in challenging clinical cases. Traditional methods to extend its reach may remain insufficient or unavailable. We describe two modifications to the conventional pedicled flap to extend its reach to the limits, namely (1) selecting a distal perforator supplemented by the nonsizeable perforator harvest technique, and (2) the double-pivot technique adding an additional rotation to the flap à la propeller perforator flap. The increased reach not only improves reconstructive success, but also opens up new applications for this workhorse flap.
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Affiliation(s)
- Weihao Liang
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hsing-Fu Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, Kaohsiung City, Taiwan
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan
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Kasielska-Trojan A, Sitek A, Gabryszewski M, Antoszewski B. Digit ratio and the femoral circumflex artery perforator: A sex-dependent association between the vascular system of the thigh and prenatal sex hormones? Early Hum Dev 2024; 188:105901. [PMID: 38041919 DOI: 10.1016/j.earlhumdev.2023.105901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The anterolateral thigh flap (ALTF) is a type of free flap which is commonly used in reconstructive surgery procedures and is based on the perforator from femoral circumflex artery. Some authors found that the location of the perforator differs between sexes. OBJECTIVE To verify the influence of prenatal sex hormones (as measured by 2D:4D) on the morphology of the perforator of the descending branch of the femoral circumflex artery. METHODS 88 participants (43 women) of a mean age of 28.5 years (SD 8.1 years) had the following measurements performed: height and weight; right and left-hand 2nd and 4th fingers' lengths; and distance from anterior superior iliac spine to the perforator from descending branch of lateral femoral circumflex artery related to the thigh length (right and left) (AP ratio). RESULTS Right 2D:4D and Dr-l (right minus left 2D:4D) were dimorphic, similarly to AP ratio (right and left), which in women was significantly higher than in men. A significant correlation was found between right and left 2D:4D and location of the perforator of the left thigh in men. The higher right and left 2D:4D (more feminine) the higher the left AP ratio (more feminine). CONCLUSION Our findings suggest that the location of perforator of femoral circumflex artery may be influenced by prenatal sex steroids such that low prenatal testosterone and high prenatal oestrogen are correlated to high AP (lower branching of the artery).
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Affiliation(s)
- Anna Kasielska-Trojan
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Medical University of Lodz, Lodz, Poland.
| | - Aneta Sitek
- Department of Anthropology, University of Lodz, Poland
| | - Mateusz Gabryszewski
- Individual Course of Study in Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Lodz, Lodz, Poland
| | - Bogusław Antoszewski
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Medical University of Lodz, Lodz, Poland
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Gabryszewski M, Kasielska-Trojan A, Sitek A, Antoszewski B. Variability of anterolateral thigh flap perforator locations - clinical implications. POLISH JOURNAL OF SURGERY 2023; 96:36-40. [PMID: 38348979 DOI: 10.5604/01.3001.0053.9856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
<b><br>Introduction:</b> The anterolateral thigh flap is an example of a free flap widely applied for reconstruction of tissues within various areas of the body.</br> <b><br>Aim:</b> The aim of the study was to determine the most common locations of the ALT flap perforators in men and women as well as to clarify any potential differences in the location of the vessel in male vs. female subjects.</br> <b><br>Material and method:</b> In years 2021-2022, a study was conducted at the Plastic, Reconstructive, and Aesthetic Surgery Clinic in a group of 90 volunteers (45 women and 45 men, a total of 180 lower extremities) to determine the location of the anterolateral thigh flap perforator against the flap surface using a portable Doppler probe.</br> <b><br>Results:</b> Variable locations were revealed for the anterolateral thigh flap perforator within the study. In women, the perforator is located more distally from the anterior superior iliac spine, most frequently within the inferolateral quadrant, while being located closer to the anterior superior iliac spine, and most frequently within the superolateral quadrant, in men. No perforator was found in 3.3% of the examined limbs. No statistically significant differences were observed between the course of the perforators within the left and right lower limbs in individual patients.</br> <b><br>Conclusions:</b> The location of the ALT flap perforator is subject to sexual dimorphism, which facilitates the investigation area being narrowed down to the well-defined locations of its most frequent occurrence when planning anterolateral thigh flap reconstructive procedures.</br>.
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Affiliation(s)
- Mateusz Gabryszewski
- Individual Course of Study - Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Medical University of Lodz, Poland
| | - Anna Kasielska-Trojan
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Medical University of Lodz, Poland
| | - Aneta Sitek
- Department of Anthropology, University of Lodz, Poland
| | - Bogusław Antoszewski
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Medical University of Lodz, Poland
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Yassin AM, Kanapathy M, Khater AM, El-Sabbagh AH, Shouman O, Nikkhah D, Mosahebi A. Uses of Smartphone Thermal Imaging in Perforator Flaps as a Versatile Intraoperative Tool: The Microsurgeon's Third Eye. JPRAS Open 2023; 38:98-108. [PMID: 37753532 PMCID: PMC10518327 DOI: 10.1016/j.jpra.2023.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction In this study, we evaluate the versatility of smartphone thermal imaging technology as a valuable intraoperative modality in different stages of perforator flap surgery aiming to minimize the complications and achieve the best postoperative outcome. Patients and methods Thermography was performed in 20 perforator flaps in 20 patients at different surgical stages in three different ways to identify the most dominant perforator: first, by measuring the surface temperature of the skin; second, by using the dynamic infrared thermography technique; and third, by assessing the perfusion pattern when the flap was supplied by each perforator separately. Thermography was used to help in discarding the least perfused area of the flap. After microvascular anastomosis, the flap reheating pattern was evaluated. Results Seventeen free and three pedicled perforator flaps were included. Intraoperatively, each of the selected perforators had a corresponding hotspot. The perforator with the hottest hotpot, best rewarming, and provision of best flap perfusion on thermography was found clinically dominant. After microvascular anastomosis in free flaps, rapid rewarming was recorded in 15 cases. In two deep inferior epigastric perforator flaps, no rapid rewarming was observed. The pedicle was kinked in one case and there was a venous insufficiency in another case that required a cephalic turndown. All flaps showed good perfusion on thermography after inset. Conclusion Smartphone thermography has proven to be a valuable, cheap, rapidly employed, and objective tool not only for the design of perforator flaps, but also for the decision making intraoperatively to achieve the best surgical outcome.
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Affiliation(s)
- Ahmed M. Yassin
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Egypt
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Muholan Kanapathy
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Amr M.E. Khater
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Ahmed Hassan El-Sabbagh
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Omar Shouman
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
- Division of Surgery & Interventional Science, University College London, London, United Kingdom
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Lu G, Su Y, Jiang Y, Yang L, Wang Y, Shi G, Zhang F, Duan X, Hu H. Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in CT angiography via sublingual glyceryl trinitrate. Clin Radiol 2023; 78:e791-e797. [PMID: 37574403 DOI: 10.1016/j.crad.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 08/15/2023]
Abstract
AIM To investigate the improvement of image quality and visualisation of the anterolateral thigh (ALT) flap perforators on computed tomography angiography (CTA) after administration of sublingual glyceryl trinitrate (GTN). MATERIALS AND METHODS Sixty patients with oral lesions received thigh CTA examinations were divided randomly into two groups after administration of sublingual GTN (GTN group) or without administration of sublingual GTN (non-GTN group). Two radiologists calculated the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and assessed the image quality of each vessel. Besides, the grade of thigh artery, the lumen diameter of deep femoral artery, lateral circumflex femoral artery (LCFA), the descending branch of LCFA and its proximal and distal perforators, and the number and type of visible perforators were evaluated quantitatively. RESULTS The SNR and CNR were not significantly different between the two groups (p>0.05). The image quality of CTA in the GTN group was significantly better than that in the non-GTN group (p<0.01). The lumen diameters of the deep femoral artery, LCFA, the descending branch of LCFA and its perforators were significantly larger in the GTN group than those in the non-GTN group (p<0.01). Compared with the non-GTN group, the number of visible perforators and the number of visible septocutaneous perforators were significantly more in the GTN group, and the qualitative grade of visible perforators was significantly higher (p<0.001). CONCLUSIONS The administration of sublingual GTN in preoperative thigh CTA can improve the image quality and visualisation of perforator vessels, thus could help surgeons to select the optimum ALT flaps.
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Affiliation(s)
- G Lu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Jiang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - L Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Wang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - G Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - F Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - X Duan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - H Hu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China.
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Liu SW, Hanick AL, Meleca JB, Roskies M, Hadford SP, Genther DJ, Ciolek PJ, Lamarre ED, Ku JA. The profunda artery perforator flap for head and neck reconstruction. Am J Otolaryngol 2023; 44:103772. [PMID: 36584596 DOI: 10.1016/j.amjoto.2022.103772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.
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Affiliation(s)
- Sara W Liu
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Andrea L Hanick
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Joseph B Meleca
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Michael Roskies
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Stephen P Hadford
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Dane J Genther
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Peter J Ciolek
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA
| | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44195, USA.
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11
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Qiao Z, Wang X, Deng Y, Li Q, Zan T, Sun Y, Xiong X, Meng X, Li W, Yi Z, Li X, Fang B. Clinical Application of Pre-Expanded Perforator Flaps. Facial Plast Surg Aesthet Med 2023; 25:68-73. [PMID: 34619036 DOI: 10.1089/fpsam.2021.0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Challenging large soft tissue defects are typically treated with microvascular free tissue transfer; however, success has been noted with pre-expanded perforator flaps. Objective: To report outcomes and complications from pre-expanded perforator flaps. Methods: A retrospective chart review of patients undergoing tissue reconstruction with pre-expanded perforator flaps between 2014 and 2020. Data collection included flap type, defect characteristics, and complications. Results: All 29 patients had successful flap reconstruction without major complication. The median area of tissue defect was 17 × 13 cm2 (range 7 × 4 to 27 × 24 cm2). Mean tissue expansion period was 15.2 weeks (range 9-26 weeks). The most common flap was the pre-expanded internal mammary artery perforator flaps. Conclusion: The findings of this study suggest that combining tissue expansion with a perforator flap for large tissue reconstruction can be successful with limited complications. This technique may allow a larger pliable skin flap that deserves further investigation.
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Affiliation(s)
- Zhihua Qiao
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiancheng Wang
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yiwen Deng
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Tao Zan
- Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Yang Sun
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Xiong
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xianxi Meng
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wenbo Li
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhongjie Yi
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaofang Li
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
| | - Borong Fang
- Department of Plastic and Burns, Second Xiangya Hospital, Central South University, Changsha, China
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12
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Yu XX, Yang SF, Ji CS, Qiu SQ, Qi YD, Wang XM. A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap. Insights Imaging 2022; 13:190. [PMID: 36512153 DOI: 10.1186/s13244-022-01318-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anterolateral thigh perforator (ALTP) flap is considered a versatile flap for soft tissue reconstruction. Computed tomography angiography (CTA) is used for mapping perforator in abdominal-based reconstruction; however, it is less commonly used in ALTP due to its poor imaging efficacy. In this study, we introduced a novel CTA technique for preoperative localization and design of ALTP flap and evaluated its value in directing surgical reconstruction. RESULTS Thirty-five patients with soft tissue defects were consecutively enrolled. Modified CTA procedures, such as sharp convolution kernel, ADMIRE iterative reconstruction, 80 kV tube voltage, high flow contrast agent and cinematic rendering image reconstruction, were used to map ALTPs. A total of 287 perforators (including 884 sub-branches) were determined, with a mean of 5 perforators per thigh (range 2-11). The ALTPs were mainly concentrated in the "hot zone" (42%, 121/287) or the distal zone (41%, 118/287). Most perforators originated from the descending branch of the lateral circumflex femoral artery (76%, 219/287). Three perforator types, namely musculocutaneous (62%, 177/287), septocutaneous (33%, 96/287), and mixed pattern (5%, 14/287), were identified. The median pedicle length measured by two methods was 4.1 cm (range 0.7-20.3 cm) and 17.0 cm (range 4.7-33.9 cm), respectively, and the median diameter of the skin flap nourished by one perforator was 3.4 cm (IQR 2.1-5.7 cm). Twenty-eight ALTP flaps were obtained with the guidance of CTA, and 26 flaps survived after follow-up. CONCLUSIONS The proposed CTA mapping technique is a useful tool for preoperative localization and design of ALTP flap.
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Affiliation(s)
- Xin-Xin Yu
- Department of Radiology, Shandong Provincial Hospital, Shandong University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Shi-Feng Yang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Cong-Shan Ji
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Shen-Qiang Qiu
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Yao-Dong Qi
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
| | - Xi-Ming Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
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13
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Illg C, Krauss S, Rachunek K, Hoffmann S, Denzinger M, Kolbenschlag J, Daigeler A, Schäfer RC. Does leg dominance influence anterolateral thigh flap perforators? Microsurgery 2022; 42:817-823. [PMID: 36200703 DOI: 10.1002/micr.30968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/20/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Thorough knowledge of perforator anatomy can facilitate anterolateral thigh (ALT) free flap harvest. The selection of the right or left thigh as donor area may be supported by preoperative perforator imaging and practical considerations. The study aims to determine if the leg dominance should be taken into account, when choosing the donor thigh for ALT free flap harvest, as muscle mass and perfusion might influence perforator quantity. METHODS ALT perforators were localized by color-coded duplex sonography and dynamic infrared thermography on both thighs within a defined 250 × 80 mm area in 24 subjects. Perforator number and thickness of subcutaneous tissue and muscle layer were compared in dominant and nondominant legs. RESULTS We found no statistically significant difference comparing sonographically identified ALT perforator numbers and hot spot numbers in dominant and nondominant legs. Yet, we found high interindividual differences. The comparison of subcutaneous tissue and muscle thickness yielded no significant difference. CONCLUSIONS Our study yielded no evidence for preference of the dominant or nondominant leg in ALT free flap harvesting. As we found high interindividual differences in perforator number, we suggest to rely on preoperative perforator imaging when choosing the ALT free flap donor thigh.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Sebastian Hoffmann
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Markus Denzinger
- Department of Pediatric Surgery, University Medical Center, Regensburg, Germany
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University, Tuebingen, Germany
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14
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Kalra GS, Gupta S, Kalra S. Pedicle First Anterior Approach to Harvest Anterolateral Thigh Flap—Review of 304 Cases. Indian J Plast Surg 2022; 55:272-276. [PMID: 36325079 PMCID: PMC9622332 DOI: 10.1055/s-0042-1756128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background
Although considered as a workhorse flap, the anterolateral thigh (ALT) flap has a steep learning curve that makes it difficult for microsurgeons to perform it early in their practice. In over 85% of patients, the perforator takes an intramuscular course making it difficult for beginners to safely secure the perforator dissection. In this technique, the pedicle is dissected first, utilizing the proximal incision by palpating the groove in between vastus lateralis and rectus femoris on the anterior aspect and extending the incision from 2 to 3 cm distal to the inguinal ligament to the flap markings caudally. Exposing the pedicle first makes it easier to proceed toward the skin perforator due to its easy identification and larger size at its origin.
Patients and Methods
This retrospective study was conducted from 2005 to 2020 in which 304 ALT flaps were performed by the pedicle first technique. Flap harvest time, incidence of injury to the skin perforator during harvest, flap re-exploration rates, and postoperative complications including incidence of flap necrosis, infection, and bleeding were the parameters that were measured.
Results
This study included a total of 304 patients of which 220 were male (72.3%). The average flap harvest time was 26 ± 3.2 minutes. Adverse events included perforator injury (
n
= 1), flap re-exploration (
n
= 15), and complete flap loss (
n
= 8). The last eight patients were reconstructed secondarily with ALT flap from the opposite side and free latissimus dorsi flap (
n
= 2).
Conclusion
The pedicle first technique makes ALT flap harvest easy, safe, and faster for plastic surgeons. The chances of injury to the skin perforator are markedly less thereby reducing postoperative complications.
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Affiliation(s)
- GS Kalra
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Samarth Gupta
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
| | - Sushrut Kalra
- Department of Plastic, Reconstructive and Burns Surgery, SMS Hospital Jaipur, Rajasthan, India
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15
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Rao P, Luo S, Wang L, Li Y, Fu G, Xiao J. Computed tomography angiography-aided individualized anterolateral thigh flap design in the reconstruction of oral and maxillofacial soft tissue defects. Oral Surg Oral Med Oral Pathol Oral Radiol 2022; 134:143-150. [PMID: 35430179 DOI: 10.1016/j.oooo.2021.12.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate a novel method and computed tomography angiography (CTA) for locating anterolateral thigh flap (ALTF) perforators to design individualized ALTFs to reconstruct maxillofacial soft tissue defects. STUDY DESIGN This study comprised a group of 36 patients (CTA group) with malignant oral and maxillofacial tumors who underwent CTA and who received individualized ALTFs and a group of 28 patients (control group) with the same condition but without preoperative CTA examination and with nonindividualized ALTFs. ALTFs in the CTA group were designed and harvested using the locating device and CTA, whereas ALTFs in the control group were designed and harvested according to each surgeon's experience. RESULTS Fifty perforators were located and 36 ALTFs harvested in the CTA group. In the control group, 34 perforators were located and 28 ALTFs harvested. Less time was required to locate the perforators in the CTA group. Moreover, the CTA group had a higher flap survival rate and better patient satisfaction regarding the postoperative aesthetics and phonetic and swallowing functions. CONCLUSIONS The results suggest that CTA and the locating device can be used to accurately locate ALTF perforators and that this method aids in the design and harvesting of individualized ALTFs to achieve good functional and aesthetic outcomes.
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Affiliation(s)
- Pengcheng Rao
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China
| | - Shihong Luo
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China
| | - Lei Wang
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China
| | - Yong Li
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China
| | - Guangxin Fu
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China; National Key Clinical Specialty, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Jingang Xiao
- Department of Oral and Maxillofacial Surgery, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China; National Key Clinical Specialty, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Orofacial Reconstruction and Regeneration Laboratory, The Affiliated Stomatology Hospital of Southwest Medical University, Luzhou 646000, China.
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16
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Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients. Ann Plast Surg 2022; 89:185-190. [PMID: 35703220 DOI: 10.1097/sap.0000000000003236] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The anterolateral thigh flap is one of the most widely used flaps because it has the advantages of less damage to the donor site, no sacrifice of main blood vessels, and abundant soft tissue. However, the application of anterolateral thigh flap in children is relatively rare because of small blood vessels and rapid physiological changes. The aim of this study was to explore the effectiveness and characteristics of free anterolateral thigh flaps for the reconstruction of extremity soft tissue defects in pediatric patients. PATIENTS AND METHODS This study included 26 pediatric patients, with an average age of 6.7 years (range, 2-13 years). There were 5 cases of upper limb defects and 21 cases of lower limb defects, all of which were accompanied by exposed bones or tendons. The causes of defects included traffic injury in 9 cases, mechanical injury in 7 cases, collision injury in 4 cases, spoke injury in 3 cases, cicatricial contracture in 2 cases, and fibroma in 1 case. All defects were reconstructed with free anterolateral thigh flaps. RESULTS Twenty-six anterolateral thigh flaps were harvested, including 15 fasciocutaneous flaps and 11 musculocutaneous flaps. The mean size of the flap was 73.4 cm2 (range, 4 × 3 to 24 × 8 cm). The donor sites were sutured directly in 19 cases and underwent split-thickness skin grafting in 7 cases. There were 3 cases of vascular crisis, 3 cases of flap edge necrosis, 3 cases of infection, 1 case of pressure ulcer, and 1 case of dehiscence after surgery. Eleven patients had scar hyperplasia in the donor site. A total of 34 reoperations were performed, including 14 flap debulking, 7 debridement, 4 skin graft, 3 vascular crisis re-exploration, and 6 other procedures. CONCLUSIONS Free anterolateral thigh flap was a safe and reliable option for reconstructing soft tissue defects of extremities in pediatric patients. Notably, the incidence of scar hyperplasia in the donor site and the possibility of reoperation in pediatric patients were higher than those in adult patients.
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17
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Initial Investigation of Clinical Value of Noise-Optimized Virtual Monoenergetic Images Derived From Dual-Energy Computed Tomography Angiography in Preoperative Perforator Planning of Anterolateral Thigh Flap Transplantation. J Comput Assist Tomogr 2022; 46:560-567. [PMID: 35405721 DOI: 10.1097/rct.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To objectively and subjectively assess the image characteristics of noise-optimized virtual monoenergetic images [MEI (+)] and polyenergetic images (PEIs) from dual-energy computed tomography angiography and then to explore the clinical value of the optimal MEI (+) in preoperative perforator planning of anterolateral thigh (ALT) flap transplantation. METHODS Sixteen patients (32 thighs) who underwent lower extremity run-off dual-energy computed tomography angiography for planning ALT flap transplantation were enrolled. One standard PEI and 5 MEI (+) in 10-keV intervals (range, 40-80 keV) were reconstructed. First, we compared the image quality subjectively (branch order, image quality, and vascular network continuity) and objectively (vascular attenuation, image noise, signal-to-noise ratio, and the contrast-to-noise ratio). Then, we compared the clinical value (number, type, source artery, pedicle length, caliber, and location of all sizable perforators) between the optimal MEI (+) and PEI groups. RESULTS The 40-keV MEI (+) was rated superior subjective and objective image quality metrics to PEI (all P < 0.001). Compared with PEI, 40 keV MEI (+) increased the number of visible perforators, the percentage of perforators with identifiable types, and the measurable length of perforator pedicle (all P < 0.001). CONCLUSIONS We recommend 40 keV MEI (+) for the visualization of perforators and their contribution to the selection and location of suitable perforators in preoperative planning for ALT flaps.
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18
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He J, Guliyeva G, Wu P, Yu F, Qing L, Tang J. Reconstruction of Complex Soft Tissue Defects of the Heel With Versatile Double Skin Paddle Anterolateral Thigh Perforator Flaps: An Innovative Way to Restore Heel Shape. Front Surg 2022; 9:836505. [PMID: 35237651 PMCID: PMC8884269 DOI: 10.3389/fsurg.2022.836505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Complex heel defects constitute a significant challenge for plastic surgeons. Objectives In this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored. Methods From January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases. Results Flap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm2 to 22 × 10 cm2, and the size of a muscle segment ranged from 6 × 3 × 1 cm3 to 10 × 3 × 2 cm3. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm). Conclusion Double skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.
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Affiliation(s)
- Jiqiang He
- Xiangya Hospital, Central South University, Changsha, China
| | - Gunel Guliyeva
- The Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Panfeng Wu
- Xiangya Hospital, Central South University, Changsha, China
| | - Fang Yu
- Xiangya Hospital, Central South University, Changsha, China
| | - Liming Qing
- Xiangya Hospital, Central South University, Changsha, China
| | - Juyu Tang
- Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Juyu Tang
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19
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Ma C, Gao W, Abdelrehem A, Zhu D, Zhu Y, Sun J, Shen Y. Anteromedial thigh septocutaneous perforator flap as a first choice for head and neck reconstruction: A clinical algorithm based on perforator-pedicle relationship. Oral Oncol 2022; 126:105738. [PMID: 35114613 DOI: 10.1016/j.oraloncology.2022.105738] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anterolateral thigh perforator flaps (ALTPFs) have long been considered workhorse flaps for head and neck reconstructions. However, in some instances, anteromedial thigh septocutaneous perforator flaps (AMTPFs) are easier to harvest than ALTPFs. This study aimed to determine when and how the AMTPF should be considered the first choice as a reconstructive tool. METHODS A retrospective cohort study was performed in the Department of Oral and Maxillofacial Surgery-Head & Neck Oncology, Shanghai Ninth People Hospital, from January 2014 to December 2018. Both the perforator-pedicle relationships and postoperative functional outcomes were compared. RESULTS A total of 168 patients were included in this study, among whom 49 underwent AMTPF reconstructions. The AMTPF perforators in this study were mostly septocutaneous (n = 38, 77.5%). Notably, the AMTPF perforators mainly originated from the medial branch of the descending branches of the lateral circumflex femoral arteries (n = 44, 89.8%), while for the other 5 patients, the perforators were found to originate from the superficial femoral arteries. Additionally, the average pedicle length of the AMTPFs was 8.7 cm (range: 6.0 to 13.0 cm), which was comparable to that of the ALTPFs (8.9 cm) (p = 0.442). The postoperative complication rate and functional outcomes were comparable between the two groups. The algorithm and harvesting approaches are presented. CONCLUSIONS The role of AMTPF should not be downplayed. After careful preoperative evaluation, we believe that AMTPF should not be considered a second choice in patients with sizable septocutaneous perforators.
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Affiliation(s)
- Chunyue Ma
- Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Weijin Gao
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ahmed Abdelrehem
- Department of Craniomaxillofacial and Plastic Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Dan Zhu
- Department of Radiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, Chinas
| | - Yaxin Zhu
- Department of CT Clinical Research, CT Business Unit, Canon Medical Systems (China) CO. LTD., Beijing, China
| | - Jian Sun
- Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.
| | - Yi Shen
- Department of Oral Maxillofacial-Head Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.
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20
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Reconstruction of Giant Defects Due to Electrical and Radiation Burns in the Lower Leg with Free Anterolateral Thigh Flaps. J Plast Reconstr Aesthet Surg 2022; 75:1596-1601. [DOI: 10.1016/j.bjps.2021.11.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/22/2021] [Accepted: 11/12/2021] [Indexed: 11/19/2022]
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21
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Thomas B, Haug V, Falkner F, Arras C, Nagel SS, Boecker A, Schmidt VJ, Kneser U, Bigdeli AK. A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times. Microsurgery 2022; 42:40-49. [PMID: 34165203 DOI: 10.1002/micr.30775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 03/15/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. METHODS 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. RESULTS Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04). CONCLUSIONS Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Christian Arras
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Arne Boecker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Volker J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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Yin J, Wang L, Yang G, Qin X, Xiong P. Correlation Between Body Mass Index and Anterolateral Thigh Flap Thickness: A Retrospective Study From a Single Center in China. Front Surg 2021; 8:748799. [PMID: 34708071 PMCID: PMC8542684 DOI: 10.3389/fsurg.2021.748799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: During repair of oral and maxillofacial soft tissue defects, organ function is largely related to the amount of thickness of the flap. However, there are few studies on the influencing factors of the thickness of the flap. In this retrospective study, we aim to explore the correlation between body mass index (BMI) and anterolateral thigh (ALT) flap thickness by computed tomography (CT) and ultrasound and provide guidance for evaluating the ALT flap thickness before surgery. Methods: We selected three points A, B, and C on ALT flap and two skilled clinicians measured the thickness of these points. Age and gender as covariates and evaluated by the Chi-square analysis. Inter-group differences between the two BMI groups were examined by the student t test. Intra-group differences within each BMI group were tested by ANOVA. Linear regression analysis was performed to examine the relationship between BMI and ALT flap thickness. Results: One hundred sixty patients measured by CT were included in this study, and the ALT flap thickness measured by CT were 8.96 mm and 11.00 mm (P < 0.0001, t test) at point B in groups with BMI<24.0 and BMI≥24.0, respectively. The thicknesses at points A, B, and C were significantly correlated with the BMI (P < 0.001, correlation analysis, r = 0.462, 0.372, and 0.349 at the points A, B, and C, retrospectively, Pearson test). Conclusion: There was a significant correlation between the ALT flap thickness and BMI. A higher BMI was correlated with a thicker ALT flap.
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Affiliation(s)
- Jianxin Yin
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Wang
- Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, China
| | - Gongxin Yang
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingjun Qin
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Oral Diseases, Shanghai, China.,Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, Shanghai, China
| | - Ping Xiong
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Gholami M, Shaban B, Hejazi A, Sazegar G, Soufizadeh R. Anatomical Variations of Anterolateral Thigh Flap: A Fresh Cadaver Dissection Study. World J Plast Surg 2021; 10:18-24. [PMID: 34912663 PMCID: PMC8662690 DOI: 10.29252/wjps.10.3.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/18/2020] [Accepted: 09/02/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The anterolateral thigh (ALT) flap is one of the fasciocutaneous flaps in the thigh region based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral artery (LCFA). This cadaveric study aimed to explore the variability of ALT flap anatomy. METHODS Ten ALT flaps were dissected (2016-20117, Mashhad Legal Medicine Organization) in 10 fresh cadavers (7 males and 3 females). Flaps were marked in a 15 cm area centered on the middle point of a line drown from anterior superior iliac spine to the lateral surface of the patella. Dissection began by searching the skin perforators and then continued along the pathway of the vascular pedicle. RESULTS The average distance of ASIS-Patella was 44.6 cm. The mean number of skin perforators was 2.4 (ranged from 0 to 4). In one case, we did not find any skin perforator. The majority of skin perforators were musculocutaneous from descending branch of LCFA (66.7%) and the remaining were septocutaneous (33.3%). The mean length of vascular pedicle was 10.17 cm. The average diameter of vascular pedicle was 2.78 mm for the artery and 3.79 mm for the vein. The average time of flap harvesting was 85.3 min (ranged from 50 to 125 min). CONCLUSION The skin perforators supplying the ALT flap showed significant variability in number, location and course. The cadaveric study could enhance the anatomic knowledge and operative skills of ALT flap harvesting.
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Affiliation(s)
- Mahdi Gholami
- Oral & Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Baratollah Shaban
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Arya Hejazi
- Legal Medicine, Member of Legal Medicine Research Center, Legal Medicine Organization, Mashhad, Iran
| | - Ghasem Sazegar
- Department of Anatomy and Cell Biology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rashid Soufizadeh
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
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Li J, Xiong H, Li G, Zhou P, Ai F, Wang K, Chen J. Free Flap Reconstruction of Extremity Defects in Pediatric Patients. HANDCHIR MIKROCHIR P 2021; 53:349-355. [PMID: 34371519 DOI: 10.1055/a-1351-0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients. METHODS From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100). CONCLUSION The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.
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Illg C, Krauss S, Rothenberger J, Kolbenschlag J, Daigeler A, Schäfer RC. Air Flow Cooling Improves Anterolateral Thigh Perforator Mapping Using the FLIR ONE Thermal Camera. J Reconstr Microsurg 2021; 38:144-150. [PMID: 34229351 DOI: 10.1055/s-0041-1731641] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Due to the variable vascular anatomy preoperative perforator mapping facilitates anterolateral thigh (ALT) free flap harvesting. Dynamic infrared perforator imaging can assist preoperative planning by displaying hot spots that represent angiosomes. This study aims to compare previously described precooling methods to develop a standardized simplified protocol for ALT perforator planning. METHODS Fifty thighs were examined with a FLIR ONE thermal camera. Four different cold challenges, including alcoholic disinfection, wet laparotomy sponge cooling, fan cooling, and cold pack application, were compared. Hot spot locations within a 250 mm × 80 mm area were compared double-blinded to perforator locations determined by Doppler ultrasonography considered as gold standard. RESULTS The matching rate of thermographic hot spots and sonographically identified perforators was 34.9 ± 22.2%. An increased matching rate of 62.2 ± 42.2% was noted taking only favored perforators (septocutaneous course, diameter >1 mm, distance <3 cm to the center, and visible concomitant veins) into account. Precooling with a fan followed by alcoholic disinfection provided clearest thermograms and fastest results. CONCLUSION Thermographic imaging is a reliable method for perforator imaging. Its supplemental use to ultrasound may reduce examination time and yield additional information. Precooling by air flow or alcoholic disinfection can be easily implemented and provide the best thermograms. The matching rate of thermographic hot spots and perforators increases when taking only clinically relevant perforators into account. Thermal perforator mapping therefore reduces distraction by negligible perforators.
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Affiliation(s)
- Claudius Illg
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Germany
| | - Sabrina Krauss
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Germany
| | - Jens Rothenberger
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Jonas Kolbenschlag
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Germany
| | - Ruth Christine Schäfer
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Germany
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26
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Anatomical Variations of Anterolateral Thigh Flap: A Fresh Cadaver Dissection Study. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.3.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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27
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Li RG, Zeng CJ, Yuan S, Hu JJ, Zhang P, Chen YB, Zhao SW, Ren GH. Reconstruction of Large Area of Deep Wound in the Foot and Ankle with Chimeric Anterolateral Thigh Perforator Flap. Orthop Surg 2021; 13:1609-1617. [PMID: 34142464 PMCID: PMC8313155 DOI: 10.1111/os.13046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/12/2021] [Accepted: 04/13/2021] [Indexed: 01/17/2023] Open
Abstract
Objective To evaluate the clinical application and surgical efficacy of the chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap for the reconstruction of the large area of deep wound in foot and ankle. Methods Clinical data of 32 cases who underwent chimeric anterolateral thigh perforator flap to repair the large area of deep wound of the foot and ankle from January 2015 to December 2018 were retrospectively analyzed. The sizes of the defects ranged from 18 cm × 10 cm to 35 cm × 20 cm, with exposed tendon and bone and/or partial defects and necrosis, contaminations, accompanied by different degrees of infection. Following the radical debridement and VSD, chimeric anterolateral thigh perforator flap was employed to repair the deep wounds according to the position, site and deep‐tissue injury of the soft‐tissue defects. The skin flap and muscle flap were fanned out on the wound, and single‐ or two‐staged split‐thickness skin grafting was performed on the muscle flap. The operation time and blood loss were recorded. The survival and healing conditions of the operational site with chimeric anterolateral thigh perforator flap were evaluated post‐operationally. Complications at both recipient site and donor site were carefully recorded. Results The mean time of the operation was 325.5 min and average blood loss was 424.8 mL. Among the 32 cases, two cases developed vascular crisis, which were alleviated with intensive investigation and treatment; Four cases suffered from partial necrosis of the flap or skin graft on the muscle flap or on the residual local wound, which were improved after treatment of further dressing change and skin grafting. Another four cases experienced post‐traumatic osteomyelitis accompanied by bone defect were treated with simple bone grafting or Mesquelet bone grafting at 6–8 months after wound healing. Postoperatively, the wounds were properly healed, and the infection was effectively controlled without sinus tract forming. Overall, all 32 cases received satisfactory efficacy, without influencing subsequent functional reconstruction, and observed infection during the 12–36 months post‐operational follow‐up. Conclusion The chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap provides an effective and relative safe procedure for the repair of a large area of deep wound in the foot and ankle, particularly with irregular defect or deep dead space.
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Affiliation(s)
- Run-Guang Li
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China.,Orthopaedic Hospital of Guangdong Province, Guangzhou, China.,Academy of Orthopaedics, Guangdong Province, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, China.,Department of Orthopedics, Linzhi People's Hospital, Linzhi, China
| | - Can-Jun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China.,Orthopaedic Hospital of Guangdong Province, Guangzhou, China.,Academy of Orthopaedics, Guangdong Province, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, China
| | - Song Yuan
- Department of Orthopedics, Linzhi People's Hospital, Linzhi, China
| | - Ji-Jie Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ping Zhang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yun-Biao Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shan-Wen Zhao
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China.,Orthopaedic Hospital of Guangdong Province, Guangzhou, China.,Academy of Orthopaedics, Guangdong Province, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, Guangzhou, China
| | - Gao-Hong Ren
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Abstract
BACKGROUND The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern. METHODS All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin. RESULTS Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch. CONCLUSIONS A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.
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29
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Lin P, Kuo P, Kuo SCH, Chien P, Hsieh C. Risk factors associated with postoperative complications of free anterolateral thigh flap placement in patients with head and neck cancer: Analysis of propensity score‐matched cohorts. Microsurgery 2020; 40:538-544. [DOI: 10.1002/micr.30587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 02/26/2020] [Accepted: 03/27/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Pi‐Chieh Lin
- Department of Plastic SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine Kaohsiung Taiwan
| | - Pao‐Jen Kuo
- Department of Plastic SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine Kaohsiung Taiwan
| | - Spencer C. H. Kuo
- Department of Plastic SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine Kaohsiung Taiwan
| | - Peng‐Chen Chien
- Department of Plastic SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine Kaohsiung Taiwan
| | - Ching‐Hua Hsieh
- Department of Plastic SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine Kaohsiung Taiwan
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30
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New way to reduce the length and bulk of a two-perforator anterolateral thigh flap: a technical note. Br J Oral Maxillofac Surg 2020; 58:369-371. [PMID: 32151458 DOI: 10.1016/j.bjoms.2020.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/13/2020] [Indexed: 11/23/2022]
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31
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Homsy C, McCarthy ME, Lim S, Lindsey JT, Sands TT, Lindsey JT. Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery. Ann Plast Surg 2020; 84:S424-S430. [DOI: 10.1097/sap.0000000000002203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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The Lateral Thigh Perforator Propeller Flap: A Reliable Backup Plan for Locoregional Reconstruction in Case of Missing or Unreliable Anterolateral Thigh Perforators. Plast Reconstr Surg 2018; 143:248e-249e. [PMID: 30418308 DOI: 10.1097/prs.0000000000005154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alessa MA, Kwak SH, Lee YW, Kang ML, Sung HJ, Ahn SH, Choi EC, Kim WS. Porcine As a Training Module for Head and Neck Microvascular Reconstruction. J Vis Exp 2018. [PMID: 30320742 DOI: 10.3791/58104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5× loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.
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Affiliation(s)
- Mohammad Ali Alessa
- Department of Otolaryngology, Head and Neck Surgery, King Abdullah Medical City; Department of Otorhinolaryngology, Yonsei University, College of Medicine
| | - Sang Hyun Kwak
- Department of Otorhinolaryngology, Yonsei University, College of Medicine
| | - Young Woo Lee
- Department of Otorhinolaryngology, Yonsei University, College of Medicine
| | - Mi-Lan Kang
- Severance Biomedical Science Institute, Yonsei University, College of Medicine
| | - Hak-Joon Sung
- Severance Biomedical Science Institute, Yonsei University, College of Medicine; The George W.Woodruff School of Mechanical Engineering, Georgia Institute of Technology
| | - Soon Hyun Ahn
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine
| | - Eun Chang Choi
- Department of Otorhinolaryngology, Yonsei University, College of Medicine
| | - Won Shik Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine;
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Abstract
Objective This study was performed to evaluate two classic procedures guided by anatomic markers for harvesting the anterolateral thigh (ALT) flap: one began with an incision on the lateral side to identify perforators emerging from the muscle to the superficial tissue and to track the perforators upward to the upper stem vessel, and the other began with an incision on the medial side to identify the vessel branch from the stem artery and to track it downward to the flap perforators. Methods Twenty-eight consecutive patients with tissue defects repaired with ALT flaps were investigated; 13 and 15 patients underwent the lateral and medial incision technique, respectively. The surgeon’s subjective view regarding procedural difficulty and the operative times were statistically analyzed. Results All flaps were harvested successfully. A two-paddle flap from one thigh in the medial group failed due to necrosis; all others survived completely. Subjectively, harvesting of flaps starting with a lateral incision was somewhat difficult, and the operative time was significantly longer using the lateral technique. Conclusions Classic procedures to harvest the anterolateral thigh flap are still practicable, and starting with a medial incision is more efficient than starting with a lateral incision. Type of study/level of evidence: Therapeutic IV.
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Affiliation(s)
- Ren-Guo Xie
- Department of Hand Surgery, Shanghai First People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Songjiang, Shanghai, China
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
- Ren-Guo Xie, Shanghai Jiao Tong University First People's Hospital, 650 New Songjiang Road, Songjiang, Shanghai, 201620, China.
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